"How Honest Are Dentsits"

[Doc Smile]

I am sitting in am ethics lecture and he mentioned this 1997 article in Readers Digest about a man go to all 50 states and comparing different exams and treatment plans from each state.

Here is a link to the full article:
http://pumiliafamilydentalgroup.com/dentists.html

Here is a excerpt:
"Four months, 50,000 miles and 50 exams later, I concluded that going to the dentist is nothing to smile about. Dentistry is a stunningly inexact science. Even expecting that different dentists would have different, yet valid, opinions did not prepare me for the astounding variations in diagnoses I received. Some wanted only $500 to bring me up to good dental health. Others wanted ten, 20, even 50 times that amount. Surely they could not all be right."

I am now curious. How would you, as a dentist or dental student treating patients, if a patient came to you and referenced this article, a similar article, or questioned your honesty, how would you respond? How would you respond if they said their friend/sister/aunt got a crown from Dr X and it was half the cost.

I do not want to stir any personal arguments, but I hope this creates a positive discussion and debate on the topic of production/chairtime vs patient care, over-treatment, and responding to these type of negative attitudes from patients.

What are your thoughts?

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[whodat4life]

I am sitting in am ethics lecture and he mentioned this 1997 article in Readers Digest about a man go to all 50 states and comparing different exams and treatment plans from each state.

Here is a link to the full article:
http://pumiliafamilydentalgroup.com/dentists.html

Here is a excerpt:
"Four months, 50,000 miles and 50 exams later, I concluded that going to the dentist is nothing to smile about. Dentistry is a stunningly inexact science. Even expecting that different dentists would have different, yet valid, opinions did not prepare me for the astounding variations in diagnoses I received. Some wanted only $500 to bring me up to good dental health. Others wanted ten, 20, even 50 times that amount. Surely they could not all be right."

I am now curious. How would you, as a dentist or dental student treating patients, if a patient came to you and referenced this article, a similar article, or questioned your honesty, how would you respond? How would you respond if they said their friend/sister/aunt got a crown from Dr X and it was half the cost.

I do not want to stir any personal arguments, but I hope this creates a positive discussion and debate on the topic of production/chairtime vs patient care, over-treatment, and responding to these type of negative attitudes from patients.

What are your thoughts?

This is very interesting. I'm anxious to hear what others have to say on this. I would venture to guess that one charging higher fees would resort to the "well, you pay for what you get (quality)" argument. But nonetheless, I'm interested to hear stories from dentists who've encountered this.

 

[crooked castle]

One thing I can think of, is the varying costs of lab fees. The quality of materials and lab used to make the crown may differ. So, if a dentist is charging on the higher end, it may be due to the higher quality material and fit of the crown (as in, it won't break).

I also think that the price can be reflective of the quality of service. If a patient doesnt care about how it's done and is just looking at price of procedure and materials needed, then he might as well all go to that Walmart that is opening a clinic. Or, the patient may opt to stick with Dr. X who has been in business for 20+ years that has been highly recommended. Even though he paid a bit more, he may leave his appointment with a sounder state of mind, that he had quality treatment and an enjoyable experience. In the end it, I suppose it depends on each individual's needs.

I mean, I'm sure you've flown different airlines to the same places before right?

 

[Doc Smile]

This is very interesting. I'm anxious to hear what others have to say on this. I would venture to guess that one charging higher fees would resort to the "well, you pay for what you get (quality)" argument. But nonetheless, I'm interested to hear stories from dentists who've encountered this.

Our guest lecturer who introduced this topic was from Loma Linda!

 

[whodat4life]

Our guest lecturer who introduced this topic was from Loma Linda!

Oh wow, how neat. The guy that interviewed me for admission to dental school teaches an ethics class at LL. His name is Dr. William Hooker, an awesome guy!

 

[HoustonDAT]

I liked how the NYC dentist recommended 21 crowns and 6 veneers on a patient with 28 teeth. So the fact that he did not decide to restore 1 tooth proves that he isn't as greedy as we thought lol. I'm shocked that even after the patient told each dentist that he was satisfied with the appearance of his teeth, the vast majority still went for the homerun tx plan.

I'm only a dental student with ~5 years of assisting under my belt. From what I've seen, the doctors who had the most new patients that returned and referred others were the ones that differentiated the options to the new patient between what was absolutely essential and what was elective aesthetic enhancement. Then these dentists would present a tx plan with only the most pressing needs, and tell the new patient something to the effect of "We will do those veneers in a few months, but we need to do the RCT(whatever pressing need) asap." From the new patient's perspective, the doctor doesn't look greedy and the new patient feels that the doctor is conscientious of the new patient's finances.

Maybe I'm naive, but I think the dentists that use this, for a lack of a better phrase, "nickel and dime approach" would make more in the long run than the ones who swing for the fences every time.

 

[mike3kgt]

I liked how the NYC dentist recommended 21 crowns and 6 veneers on a patient with 28 teeth. So the fact that he did not decide to restore 1 tooth proves that he isn't as greedy as we thought lol.

When you restore entire arches, we tend to try to save patients $$ by not crowning teeth that are out of the occlusal plane/occlusion.

Remember, sometimes you don't know what you don't know.

 

[browncrack]

Once you get beyond the article appearing in reader's digest and the quality of articles to be found in that publication, the person didn't actually pay for much, if anything. Instead, he relied upon about fifty free dental opinions about what kind of treatment he needed. Try going to a mechanic, a doctor, or a real estate agent sometime. What you say you are seeking and how that is understood is never the same. Notice, he didn't go to a street clinic and get happy about the possibility of free.

The author of the piece, William Ecenbarger, is himself an op-ed writer for the Washington Post. I take issue with the many opinions from Putlizer prize winning writers found on the pages of the Washington Post. It seems that many of them disagree with each other.

 

[UCSD6]

I didn't read the article, but there are variations in fees due to areas, market situation, lab fees, etc. Also, dentistry is a pretty clear cut science, note there are multiple treatment options which are not clear cut, some which maybe better than others and some that aren't. Treatment plans are also based on the individual dentist. So, I would approach a case by sharing the different treatment plans with the patient, from there the advantages and disadvantages. If the patient is strapped for cash, then obviously they will opt for the cheaper procedure. Some dentist treat incipient caries, some don't. But believe me it is clear cut of what is wrong and what is right. You don't do root canals or place crowns instead of class one restoration.

 

[Doc Smile]

Once you get beyond the article appearing in reader's digest and the quality of articles to be found in that publication, the person didn't actually pay for much, if anything. Instead, he relied upon about fifty free dental opinions about what kind of treatment he needed. Try going to a mechanic, a doctor, or a real estate agent sometime. What you say you are seeking and how that is understood is never the same. Notice, he didn't go to a street clinic and get happy about the possibility of free.

The author of the piece, William Ecenbarger, is himself an op-ed writer for the Washington Post. I take issue with the many opinions from Putlizer prize winning writers found on the pages of the Washington Post. It seems that many of them disagree with each other.

Don't get me wrong, I do not buy into what this guy said, nor do I agree with similar publications. I understand the fallacy of his "expirement" and how un-scientific it was. He could have got a 100% different opinion from every dentist if he said he was strapped for cash, walked to the dentist next door, etc.

For us edumacted people, we can read this article and push it aside as nonsense. But to our patients, this article just becomes another peice of the distrust that is growing (or seems to be growing) in our profession.

Lastly, why did you compare dentists to mechanics and real estate agents? At least you through doctor in there. . .

 

[Doc Smile]

I'm only a dental student with ~5 years of assisting under my belt. From what I've seen, the doctors who had the most new patients that returned and referred others were the ones that differentiated the options to the new patient between what was absolutely essential and what was elective aesthetic enhancement. Then these dentists would present a tx plan with only the most pressing needs, and tell the new patient something to the effect of "We will do those veneers in a few months, but we need to do the RCT(whatever pressing need) asap." From the new patient's perspective, the doctor doesn't look greedy and the new patient feels that the doctor is conscientious of the new patient's finances.

I agree. This is the same tx planning and presentation we did for our patients. We had one sheet with, "here is everything that I would suggest to you to get back to optimal oral health but can be spread out over months and years if need be" and the "you need this stuff done asap or else your mouth is going to fall off."

That office was always bringing in new patients and every patient had a really good, trusting, and professional relationship with the docs. I am sure other business models can be used to acheive the same end goal though. Personally, (and remember by personal I mean as a D2), I cannot imagine saying to any patient they need a full mouth reconstruction after they tell me they are satisfied with their aesthetic appearance and are in generally good oral health...

 

[mike3kgt]

I cannot imagine saying to any patient they need a full mouth reconstruction after they tell me they are satisfied with their aesthetic appearance and are in generally good oral health...

Maybe. What's important to realize (quickly hopefully) is that you cannot judge other dentists on their 1) decisions or 2) treatment 100% of the time because frankly, you just weren't there when the situation occurred. I have seen it many many times. You have to pick your words wisely when a patient asks, "did my other dentist screw me up?"

Also, aesthetics and "oral health" are both subjective. Someone with large amalgams and sheared off cusps without pain may consider themselves in "good oral health". Also, similar people have extreme wear, no pain, and are generally satisfied with their esthetics may present with the chief concern of "doc, could you put a tooth in this space I've been missing for 20 years". Some person with large gold inlays may consider those the most esthetic restoration, while other would scoff at an occlusal pit amalgam restoration.

 

[Doc Smile]

Maybe. What's important to realize (quickly hopefully) is that you cannot judge other dentists on their 1) decisions or 2) treatment 100% of the time because frankly, you just weren't there when the situation occurred. I have seen it many many times. You have to pick your words wisely when a patient asks, "did my other dentist screw me up?"

Also, aesthetics and "oral health" are both subjective. Someone with large amalgams and sheared off cusps without pain may consider themselves in "good oral health". Also, similar people have extreme wear, no pain, and are generally satisfied with their esthetics may present with the chief concern of "doc, could you put a tooth in this space I've been missing for 20 years". Some person with large gold inlays may consider those the most esthetic restoration, while other would scoff at an occlusal pit amalgam restoration.

I agree with your first paragraph whole heartily. Its well defined under the ADA's code of veracity, or maybe justice, but is defined as justifiable criticism.

4.C. Justifiable Criticism. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services. Dentists issuing a public statement with respect to the profession shall have a reasonable basis to believe that the comments made are true

http://www.ada.org/1382.aspx

I understand that oral health and aesthetics are subjective. But if the pt specifically states he/she is happy with the appearance of their teeth, then they are happy with the appearance of their teeth. As far as oral health, I think the article made it clear the pt's oral health was 'good' except for the crown needed on #30. We could argue all day whether this is true or not, and not having done an exam myself or having photographic evidence with a complete chart with intra- extra-oral exam, probing depths, etc, we should take the article's word on the subject, imo.

 

[DentinBond]

Please allow me to clear up what actually happened, as I recall reading the findings when the ADA and others investigated this case.

William Ecenbarger recieved treatment plans that could be divided for convenience into three categories:
1- underdiagnosis and undertreatment. From the Stupid Lazy Dentists.
2- "mainstream" diagnosis, including a proper periodontal examination. He did, as I recall, have periodontal disease as well as a mutilated dentition from a restorative standpoint.
3- the same proper diagnosis as in (2) with the addition of elective, esthetic dentistry which in all cases was clearly explained to the patient as such- elective highly esthetic dentistry overlaying the treatment of oral disease including caries and periodontitis.

And what did William Ecenbarger do in his article? He presented the lowest, underdiagnosed, rock-bottom treatment plan as the correct treatment plan and implied that all the others were schemes of greedy dentists with the goal of making themselves rich.

William Ecenbarger comitted unethical journalism by misrepresenting the facts. He lied by omission and obfuscation.

The 60 Minutes anti-amalgam story was a similar case. Don't get me wrong, I haven't placed an amalgam restoration in over 15 years. However my reasons are at the tooth level and are best explained elsewhere:
http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/11/amalgam-politicians-and-all-the-pink-trees.html
http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/11/enamel-bonding-dentin-bonding.html

60 Minutes had it out for amalgam on the grounds of mercury health risks. They took a so-called scientific study which was in reality junk science that could never have passed peer review and reproducibility testing and they presented it as the holy grail of materials science research. Allow me to briefly explain the main flaws of the protocol:
-The animal model was the sheep. The teeth of ruminants are vastly different than those of other mammals, with both enamel and dentin on the occlusal surfaces.
-The so-called researcher ground away the amalgam restorations he had placed with a high speed handpiece with no water spray, vastly increasing the amount of mercury vapor released over the proper and accepted technique of using copious water spray when removing existing restorations.
-And astonishingly, a mercury measuring device that was designed for warehouse-sized volumes of air was not recalibrated in any way to measure the volume of air in a sheep's mouth.

So 60 Minutes lied to its public too.

Of course we know what's going on. Over the past 20 years the standards of journalism have eroded in the face of the desire to maximize profits at any cost. "News" is often about shock value leading to ratings and profits far more than it is about a fair, unbiased, or even (good heavens!) scientifically accurate report.

Listen, though- the good guys are winning. Those "stories" occurred during an era when the Gatekeepers were all-powerful. As the Internet has allowed people to find each other, connect, and make positive change in our world, and as it has allowed for the free exchange of information without the need to ask permission from powerful Gatekeepers, these kinds of worms can't do anywhere near as much damage to our dental apple. In fact, the American consumer is at this point so busy, so distracted, and so selfish that these kinds of stories now would probably have less than 1/100th the impact that they did when run.

Treat your patients with true human Connection, provide Certainty for them in a highly uncertain world, explain your diagnosis well (with images!), and clearly delineate the health from the elective and you will thrive and your patients will find you indispensable. A Linchpin in their community...

(Did you intentionally spell "Dentists" wrong in the post title?)

 

[DentinBond]

I understand now. Very interesting, thank you. Hopefully someone sued over that article.

I'm SO glad you said that, Tired! Suing would be good, yes. But we can do even better.

Seth Godin coined the term "Ideavirus" to signify an idea that spreads by interpersonal diffusion networks within a social system. Some time ago, I worked out a rubric that seems to me to illustrate our possible responses to a negative Ideavirus pretty well:

When faced with a negative Ideavirus:
Easiest: You can complain. And do nothing.
Still easy: You can be a fearmonger. (Like most of the press.)
Not so hard: You can lobby.
Some difficulty: You can litigate.
Pretty difficult: You can legislate.
Hard, but most effective in the long-term: devising and spreading a more positive, more compelling Ideavirus.

 

[jay47]

Please allow me to clear up what actually happened, as I recall reading the findings when the ADA and others investigated this case.

William Ecenbarger recieved treatment plans that could be divided for convenience into three categories:
1- underdiagnosis and undertreatment. From the Stupid Lazy Dentists.
2- "mainstream" diagnosis, including a proper periodontal examination. He did, as I recall, have periodontal disease as well as a mutilated dentition from a restorative standpoint.
3- the same proper diagnosis as in (2) with the addition of elective, esthetic dentistry which in all cases was clearly explained to the patient as such- elective highly esthetic dentistry overlaying the treatment of oral disease including caries and periodontitis.

And what did William Ecenbarger do in his article? He presented the lowest, underdiagnosed, rock-bottom treatment plan as the correct treatment plan and implied that all the others were schemes of greedy dentists with the goal of making themselves rich.

William Ecenbarger comitted unethical journalism by misrepresenting the facts. He lied by omission and obfuscation.

The 60 Minutes anti-amalgam story was a similar case. Don't get me wrong, I haven't placed an amalgam restoration in over 15 years. However my reasons are at the tooth level and are best explained elsewhere:
http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/11/amalgam-politicians-and-all-the-pink-trees.html
http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/11/enamel-bonding-dentin-bonding.html

60 Minutes had it out for amalgam on the grounds of mercury health risks. They took a so-called scientific study which was in reality junk science that could never have passed peer review and reproducibility testing and they presented it as the holy grail of materials science research. Allow me to briefly explain the main flaws of the protocol:
-The animal model was the sheep. The teeth of ruminants are vastly different than those of other mammals, with both enamel and dentin on the occlusal surfaces.
-The so-called researcher ground away the amalgam restorations he had placed with a high speed handpiece with no water spray, vastly increasing the amount of mercury vapor released over the proper and accepted technique of using copious water spray when removing existing restorations.
-And astonishingly, a mercury measuring device that was designed for warehouse-sized volumes of air was not recalibrated in any way to measure the volume of air in a sheep's mouth.

So 60 Minutes lied to its public too.

Of course we know what's going on. Over the past 20 years the standards of journalism have eroded in the face of the desire to maximize profits at any cost. "News" is often about shock value leading to ratings and profits far more than it is about a fair, unbiased, or even (good heavens!) scientifically accurate report.

Listen, though- the good guys are winning. Those "stories" occurred during an era when the Gatekeepers were all-powerful. As the Internet has allowed people to find each other, connect, and make positive change in our world, and as it has allowed for the free exchange of information without the need to ask permission from powerful Gatekeepers, these kinds of worms can't do anywhere near as much damage to our dental apple. In fact, the American consumer is at this point so busy, so distracted, and so selfish that these kinds of stories now would probably have less than 1/100th the impact that they did when run.

Treat your patients with true human Connection, provide Certainty for them in a highly uncertain world, explain your diagnosis well (with images!), and clearly delineate the health from the elective and you will thrive and your patients will find you indispensable. A Linchpin in their community...

(Did you intentionally spell "Dentists" wrong in the post title?)

Wow, thank you as well.

I just don't understand why the media does this crap.
Sure, it is "sensationalist" journalism, but at what cost of the truth? I swear, I can't stand to listen to CNN, Fox, ABC, NBC at all anymore because they are ALL so biased and unprofessional (perhaps Fox and ABC the most). And what pisses me off is that Fox goes about with this "Fair and balanced" baloney, and people actually believe it?

In response to the above poster, I do agree that dentists should always present (and I'm not implying that they didn't in this case, perhaps the author "left out" this part) treatment with regards to what is needed and what is elective. Of course some dentists do disregard this because they will only have you select treatment in terms of black and white. Either it's all or nothing, and if they can't do the ideal treatment plan, then they won't treat you. That's fine, but not always realistic for what people can afford.

I'm sure that the devil is in the details, as this poster pointed out, with regards to what really happened in this case.

 

[jay47]

Lol, I just read the part about the dental student from Creighton. Sounds about right.

 

[budda10000]

You need to get a vareity of opinions when dealing with expensive work. My two front incisors were all chipped up and I wanted to fix them. The first dentist I went to seemed to think i needed a root canal and 2 crowns.. The next two just said veneers.

 

[yappy]

I am of the thinking that no one over pays for anything. If you enter into an agreement and pay for a service or a product, without coersion, you've showed that the service or product was 'worth' it to you. If it was not you would have not paid for it.

 

[RxMTM]

I am of the thinking that no one over pays for anything. If you enter into an agreement and pay for a service or a product, without coersion, you've showed that the service or product was 'worth' it to you. If it was not you would have not paid for it.

You forgot the Patient-Provider obligation. Providers are obligated to do their best for a patient. Patients are not experts on medical topics and can be taken advantage of by professionals. There is a trust aspect that can give the provider the power to take advantage of the patient.

 

[tinman831]

There are many ways to treat a tooth and providers can charge whatever they want for the procedure. There is no clause in the ADA code of ethics stating that a dental provider must charge the least amount possible. The only requirement is that the treatment meets the minimum standard of care to resolve the diagnosis. Feel free to shop around. No one is forcing the patient to get the treatment.

 

[RxMTM]

Let's not be patient-oriented. Let's be money-oriented. Patients are a the cash cows.

 

[DrJeff]

From an ethics standpoint, the BIGGEST test that I hold myself too, is that if the patient was my mother (feel free to insert any other beloved family member that you want there), would this be the treatment plan that I would propose for her??

If that answer is "yes" then I know that I'm ethically fine.

As for the differences between treatment plans amongst dentists for the same patient, we has been said, with past clinical experiences, one HOPEFULLY learns and as a result becomes a better both diagnostician and clinician. So what one person sees in a mouth, and very well may have seen before in a different mouth a second dentist may not have had a similar experience - this can really alter a treatment plan, especially if it turned out that a certain treatment done (or maybe not done) might have resulted in a poor longterm outcome.

 

[Noble6]

Let's not be patient-oriented. Let's be money-oriented. Patients are a the cash cows.

You need to calm down. You're starting to look like a fool.

 

[Noble6]

From an ethics standpoint, the BIGGEST test that I hold myself too, is that if the patient was my mother (feel free to insert any other beloved family member that you want there), would this be the treatment plan that I would propose for her??

If that answer is "yes" then I know that I'm ethically fine.

As for the differences between treatment plans amongst dentists for the same patient, we has been said, with past clinical experiences, one HOPEFULLY learns and as a result becomes a better both diagnostician and clinician. So what one person sees in a mouth, and very well may have seen before in a different mouth a second dentist may not have had a similar experience - this can really alter a treatment plan, especially if it turned out that a certain treatment done (or maybe not done) might have resulted in a poor longterm outcome.